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Building Bridges between Neurology, Psychiatry and Psychology

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Professor of Cognitive and Behavioural Neurology ... Neurology, cognition, personality, behaviour. Open up therapeutic relationship ... – PowerPoint PPT presentation

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Title: Building Bridges between Neurology, Psychiatry and Psychology


1
(No Transcript)
2
Course aims
  • Instruct
  • Assessment, diagnosis, management of disorders in
    middle ground between neurology and psychiatry
  • Entertain
  • Always better if one is
  • Inspire
  • Ideas for your future research and service
    improvements
  • Foster excellence
  • Might as well do a really good job

3
Course aims
  • Instruct
  • Assessment, diagnosis, management of disorders in
    middle ground between neurology and psychiatry
  • Entertain
  • Always better if one is
  • Inspire
  • Ideas for your future research and service
    improvements
  • Foster excellence
  • Might as well do a really good job

4
Course aims
  • Instruct
  • Assessment, diagnosis, management of disorders in
    middle ground between neurology and psychiatry
  • Entertain
  • Always better if one is
  • Inspire
  • Ideas for your future research and service
    improvements
  • Foster excellence
  • Might as well do a really good job

5
Course aims
  • Instruct
  • Assessment, diagnosis, management of disorders in
    middle ground between neurology and psychiatry
  • Entertain
  • Always better if one is
  • Inspire
  • Ideas for your future research and service
    improvements
  • Foster excellence
  • Might as well do a really good job

6
Neurological History Taking
  • Adam Zeman
  • Professor of Cognitive and Behavioural Neurology
  • Peninsula Medical School Department of
    Psychology
  • Exeter

7
Neurological history taking
  • Predominant importance of history-taking in
    diagnosis
  • Importance of a witness history

8
Neurological history taking
  • Aims
  • Information gathering exercise
  • Neurological disorder
  • Psychosocial background
  • Informal examination
  • Neurology, cognition, personality, behaviour
  • Open up therapeutic relationship
  • Interested, sympathetic, receptive

9
Neurological history taking
  • Presenting complaint
  • One or several? Useful to list. Significance of
    many (inverse symptom law)!
  • Allow uninterrupted narrative, so far as possible
  • Clarify
  • Date of onset
  • Frequency of recurrence
  • Duration of episodes
  • Evolution
  • Nature of main symptom, in detail
  • Tempo
  • Associated features
  • Triggers
  • Exacerbating/relieving factors
  • Treatment

10
Neurological history taking
  • Headache in a 34 yr old woman
  • Onset at puberty
  • Attacks 1-3/month
  • Few hours 2 days
  • Increasing frequency/intensity past two years
  • Throbbing headache, often unilateral, either side
  • 20 minutes scintillating visual disturbance,
    preceding headache nausea, photo- and
    phonophobia with headache
  • Sleeping in at the weekend red wine
    pre-menstrual week
  • Worse upright, better lying flat in dark room,
    helped by sleep
  • Helped by aspirin taken early in attack no help
    if not.

11
Neurological history taking
  • Further questioning via initial hypothesis, for
    example
  • PD handwriting…
  • MS LHermittes, Uthoffs
  • Epilepsy tongue-biting, incontinence
  • Syncope three Ps…

12
Neurological history taking
  • Do you need to speak to an eye witness or
    informant?
  • Yes, in diagnosis of blackouts, funny turns,
    parasomnias, cognitive disorders
  • Sometimes best done with the informant alone
    (warn at start of appointment)

13
Neurological history taking
  • Some common symptom patterns
  • NMJ
  • Fatiguable weakness
  • LMN
  • Dysarthria, dysphagia
  • Distal weakness (and numbness)
  • UMN
  • Dexterity, dragging foot, exertional worsening,
    clonus, spasms (and sphincter disturbance)
  • Extrapyramidal
  • Aching, slowing up, shuffling, dexterity,
    handwriting
  • Cerebellar
  • Slurring of speech, clumsiness, unsteadiness

14
Neurological history taking
  • What do you think is wrong?
  • brain tumour (headache)
  • Multiple sclerosis (tingling)
  • Parkinsons (tremor)
  • Alzheimers (forgetfulness)
  • Epilepsy (faints)
  • What are you hoping for from this consultation?

15
Neurological history taking
  • Functional enquiry
  • Omit?!
  • General questions
  • Appetite, weight
  • Sleep
  • Concentration, memory
  • Energy
  • Pleasure
  • Mood
  • Anxiety, panic

16
Neurological history taking
  • Neurological function
  • Headache
  • Pain
  • Sensation
  • Limb function weakness, dexterity,
    coordination, gait
  • Sphincters bladder, bowel, sexual function
  • Cognitive function
  • Memory (recent, remote, routes, faces)
  • Language
  • Arithmetic
  • Planning
  • ADLs

17
Neurological history taking
  • Other systems
  • Fever, night sweats
  • Lumps and bumps, swollen glands
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary

18
Neurological history taking
  • Past Medical History
  • Previous illnesses
  • Chronic disorders
  • Operations
  • Specific queries, eg in epilepsy birth, febrile
    convulsions, head injuries, CNS infections
  • Current prescribed medication
  • Alcohol, tobacco, recreational drugs

19
Neurological history taking
  • Old notes!
  • A vital source of information
  • Past illnesses/operations (eg surgical pathology)
  • Opinions (consistent impressions…)
  • Relevant results (Caeruloplasmin)
  • Past response to treatment (epilepsy etc)

20
Neurological history taking
  • Personal, social, family history
  • Developmental milestones
  • Childhood sibship, parental occupation, homes,
    education happy, unhappy, abused
  • Major relationships including children
  • Career
  • Family history of illness neurological,
    cognitive, psychiatric

21
Neurological history taking
  • Summary
  • Key features of each element of the history
  • Presenting complaint(s)
  • Functional enquiry
  • Past medical history
  • Personal, social, family history
  • Formulation

22
Neurological history taking
  • Diagnostic hypothesis where, then what?
  • Where?
  • Muscle
  • NMJ
  • Peripheral nerve
  • Spinal cord
  • Brain
  • Brain stem, cerebellum, thalamus, basal ganglia,
    cortex/lobe

23
Neurological history taking
  • Some common symptom patterns
  • NMJ
  • Fatiguable weakness
  • LMN
  • Dysarthria, dysphagia
  • Distal weakness (and numbness)
  • UMN
  • Dexterity, dragging foot, exertional worsening,
    clonus, spasms (and sphincter disturbance)
  • Extrapyramidal
  • Aching, slowing up, shuffling, dexterity,
    handwriting
  • Cerebellar
  • Slurring of speech, clumsiness, unsteadiness

24
Neurological history taking
  • Diagnostic hypothesis where, then what?
  • What?
  • eg spinal cord syndrome
  • Compression
  • Disc
  • tumour
  • Demyelination
  • Stroke…

25
Neurological history taking
  • Whats
  • Inherited vs acquired
  • Vascular
  • Inflammatory
  • Neoplastic
  • Traumatic
  • Allergic
  • Metabolic
  • Endocrine
  • Drugs
  • Iatrogenic
  • Psychiatric
  • Mechanical/Structural
  • Degenerative
  • Deficiency
  • Sleep-related
  • Physiological

26
Bio-psycho-social analysis - of every case!
27
Neurological history taking
  • Conclusions
  • Predominant importance
  • Witness
  • Triple purpose data, examination, relationship
  • Develop a two-stage hypothesis where? what?
  • Biopsychosocial formulation
  • Ask what do you think is wrong?
  • Examination tests hypothesis from history
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